ESL Sign-Up Sheet

1. Atlanta Public Schools Adult Education Program
Verification of Eligibility for Public Benefit Affidavit
Technical College System of Georgia
Office of Adult Education
Updated for FY15 – Completetheform in ink
Last Name:_______________________________ FirstName:________________________________ Age: _____
By executingthisaffidavitunderoath,asan applicantforadulteducation,asreferencedinO.C.G.A.§50-36-1,
fromthe Technical College Systemof GeorgiaAdultEducationProgram, the undersignedapplicantverifiesone of
the followingwithrespecttomyapplicationforapublicbenefit:
1) _________ I am a UnitedStatescitizen.
2) _________ I am a legal permanentresidentof the UnitedStates.
3) _________ I am a qualifiedalienornon-immigrantunderthe Federal ImmigrationandNationalityActwithan
aliennumberissuedbythe Departmentof HomelandSecurityorotherfederal immigrationagency.
My AlienRegistrationNumber(A-number),I-94(Arrival-Departure Record) number,orother
immigrationnumberissuedbythe U.S. Departmentof HomelandSecurityorotherfederal
immigrationagencyis: _________________________________. (Forverificationthroughthe
SAVEprogram,a frontand back copyof the secure and verifiabledocumentandthe supporting
documentationmustbe attached.)
The undersignedapplicantalsoherebyverifiesthathe or she is18 years of age or olderandhas providedat least
one secure and verifiable document*,asrequiredbyO.C.G.A. §50-36-1(e)(1),withthisaffidavit.
The secure and verifiable documentprovidedwiththisaffidavitcanbestbe classifiedas:
_____________________________________________________________________.
In makingthe above representationunderoath,Iunderstandthatanypersonwhoknowinglyandwillfullymakes
a false,fictitious,orfraudulentstatementorrepresentationinanaffidavitshall be guiltyof aviolationof O.C.G.A.
§ 16-10-20, and face criminal penaltiesasallowedbysuchcriminal statute.
Executedin____________________________________ (city),Georgia.
_________________________________________
Signature of Applicant (inink)
_________________________________________
PrintedName of Applicant
*The “List of Secure andVerifiable Documents” canbe foundat http://law.ga.gov/immigration-reports.
SUBSCRIBEDAND SWORN BEFORE ME ON THIS THE
______ DAY OF __________________, 20_______
My CommissionExpires:_____________________
PRINTED NAME OF NOTARY PUBLIC:
_________________________________
SIGNATURE OF NOTARY PUBLIC (in ink):
_________________________________
Local Program POC initials:
Date:
OAE Reviewer: Date: SAVE Date:
Results:
□ Verified
□ Unverified
 Complete andSAVE Ready
SV _____________________________
SD _____________________________
 Incomplete
□ SV Doc
□ Supporting
Doc
 Restricted Visa
_______________

3. Secure and Verifiable Documents under O.C.G.A. § 50-36-2
Issued April 3, 2014 by the Office of the Attorney General, Georgia
“Secure and verifiable document”meansadocumentissuedbyastate or federal jurisdictionorrecognizedbythe
UnitedStatesgovernmentandthatisverifiable byfederalorstate law enforcement,intelligence,orhomeland
securityagencies. The term“secure and verifiable document” shall notinclude any foreignpassport unlessthe
passport is submittedwith a valid UnitedStatesHomeland SecurityForm I-94, I-94A, or I-94W,or otherfederal
documentspecifyingan alien’slawful immigrationstatus, or otherproof of lawful presence in the UnitedStates
under federal immigrationlaw,or a Matricula Consularde Alta Seguridad,matricula consular card, consular
matriculation card, consular identificationcard, or similar identificationcardissuedby a foreign government
regardlessof the holder’simmigrationstatus. Onlythose documentsapprovedandpostedbythe Georgia
AttorneyGeneral pursuanttosubsection(g) of the Code sectionshall be consideredsecure andverifiable
documents.[O.C.G.A.§50-36-2 (b)(3)]
The followinglistof secure andverifiable documents,publishedunderthe authorityof O.C.G.A.§50-36-2,
containsdocumentsthatare verifiableforidentificationpurposes,anddocumentsonthislistmaynotnecessarily
be indicative of residencyorimmigrationstatus.
• An unexpiredUnitedStatespassport or passport card
• An unexpiredUnitedStatesmilitaryidentificationcard
• An unexpireddriver’slicense oridentificationcard issuedbyone of the UnitedStates,the Districtof
Columbia,the Commonwealthof PuertoRico,Guam, the Commonwealthof the NorthernMarianasIslands,
the UnitedStatesVirginIsland,AmericanSamoa,orthe SwainIslands,providedthatitcontainsa photograph
of the beareror listssufficientidentifyinginformationregardingthe bearer,suchasname,date of birth,
gender,height,eyecolor,andaddresstoenable the identificationof the bearer
• An unexpiredtribal identificationcard of a federallyrecognizedNative Americantribe,providedthatit
containsa photographof the beareror listssufficientidentifyinginformationregardingthe bearer,suchas
name,date of birth,gender,height,eye color,andaddresstoenable the identificationof the bearer.
• An unexpiredUnitedStatesPermanentResidentCard or AlienRegistration ReceiptCard
• An unexpiredEmploymentAuthorizationDocumentthat containsa photographof the bearer
• An unexpiredpassportissuedby a foreigngovernment,providedthatsuchpassportisaccompaniedbya US
Department of HomelandSecurityForm I-94, I-94A, or I-94W,or otherfederal from specifyingan
individual’slawfulimmigrationstatus orotherproof of lawful presenceunderfederal immigrationlaw
• An unexpiredMerchantMariner Document or Merchant Mariner Credential issuedbythe US Coast Guard
• An unexpiredFASTcard, NEXUS card, or SENTRI card
• An unexpireddriver’slicense issuedbya Canadian governmentauthority
• A Certificate ofCitizenship (FormN-560or FormN-561) or a Certificate ofNaturalization (FormN-550 or
Form N-570) issuedbythe UnitedStatesDepartmentof CitizenshipandImmigrationServices(USCIS)
• CertificationofReport of Birth (FormDS-1350), a Certificationof Birth Abroad (FormFS-545), or a Consular
Report of Birth Abroad (FormFS-240) issuedbythe UnitedStatesDepartmentof State
• An original or certifiedcopyof a birth certificate issuedbyaState,county,municipal authority,orterritoryof
the UnitedStatesbearinganofficial seal
For a more detailed listing of these secure and verifiable documents, including citations, refer to the “List of Secure and
Verifiable Documents” posted on the Attorney General of Georgia website at http://law.ga.gov/immigration-reports.